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SECTION 3: LIST OF SUBSTANCES IN CONTACT WITH THE EQUIPMENT
Substance name
Reason for return and symptoms of malfunction:_____________________________________________________________________________
______________________________________________________________________________________________________________________
If you have a warranty claim:
Print your name: ________________________________________ Print your job title:_________________________________________
Print your organisation:_________________________________________________________________________________________
Print your address: _____________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Telephone number: _____________________________ Date of equipment delivery: ___________________
I have made reasonable enquiry and I have supplied accurate information in this Declaration. I have not withheld
any information, and I have followed the Return of Edwards Equipment – Procedure (HS1).
Signed: _____________________________________ Date: _______________________
Chemical
Symbol
(for example, use protective gloves, etc.)
SECTION 4: RETURN INFORMATION
• who did you buy the equipment from ?____________________________________________________
• give the supplier's invoice number_______________________________________________________
SECTION 5: DECLARATION
Precautions required
Action required after a spill,
leak or exposure
Note: Please print out this form,
sign it and return the signed
form as hard copy.
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